Healthcare Provider Details

I. General information

NPI: 1821006545
Provider Name (Legal Business Name): LARRY R BRAZLEY MD, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E 90TH DR
MERRILLVILLE IN
46410-8144
US

IV. Provider business mailing address

55 E 86TH AVE PO BOX 10645
MERRILLVILLE IN
46410-6382
US

V. Phone/Fax

Practice location:
  • Phone: 219-791-0248
  • Fax: 219-791-0251
Mailing address:
  • Phone: 219-769-1670
  • Fax: 219-738-6714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number01032396
License Number StateIN

VIII. Authorized Official

Name: LARRY R BRAZLEY
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 219-769-1670